Partial or Complete Achilles Tendon Rupture

with Phase II Rehab

A complete tear in the Achilles tendon is known as an Achilles tendon rupture. The Achilles tendon, which is also known as the heel cord, connects the large calf muscles (Gasctrocnemius and Soleus) to the heel bone (calcaneus) and is needed for proper functioning of the calf muscles. The calf muscles are required for pushing the foot downward and are necessary for walking, running, and jumping.

SYMPTOMS

"Pop" or rip heard or felt at the back of the heel at the time of injury.

Pain and weakness when moving the foot (especially when pushing down with the front of the foot). If you have ruptured the tendon completely, you will not be able to rise on your toes on the injured leg. The pain can sometimes be severe. With a partial rupture, you may still be able to move your foot, and you may experience only minor pain and swelling.

Tenderness, swelling, warmth, and redness around the Achilles tendon.

Bruising at the Achilles tendon and heel after 48 hours.

CAUSES

Achilles tendon rupture is most commonly caused by a sudden force placed upon the Achilles tendon that is greater than the tendon can withstand (jumping, hurdling, or starting a sprint).

Achilles tendon rupture may also occur from direct trauma or injury to the lower leg, foot, or ankle.

RISK INCREASES WITH:

Sports that require sudden, explosive muscle contraction, such as those involving jumping and quick starts, running or contact sports.

Poor strength and flexibility.

Previous Achilles tendon injury.

Untreated Achilles tendinitis.

Corticosteroid injection into the Achilles tendon.

Medical conditions, such as decreased circulation due to any cardiovascular medical problem or obesity.

PREVENTION

Warm up and stretch properly before activity.

Allow for rest and recovery between activities.

Maintain physical fitness:

Ankle and leg flexibility.

Muscle strength and endurance.

Cardiovascular fitness.

Taping, protective strapping, or an adhesive bandage may be recommended before practice or competition.

PROGNOSIS

If treated properly, Achilles tendon ruptures are usually curable in 4 to 9 months.

RELATED COMPLICATIONS

Weakness of the calf muscles can occur, especially if the rupture goes untreated.

Repeat rupture of the tendon is possible even after treatment.

Prolonged disability can occur.

Risks of surgery include infection, bleeding, injury to nerves and impaired wound healing.

TREATMENT

Initial treatment involves removing all weight from the affected leg. Ice, medication, compression bandages, and elevation of the leg may be used to help reduce pain and inflammation.

Definitive treatment options include: surgical for complete tears and nonsurgical treatment for a partial tear. The return to sports is usually about the same with either treatment course but can occur a few weeks sooner with surgery.

Nonsurgical treatment can be used only for a partial rupture of the tendon. The affected leg is placed in a long cast (from foot to groin) to immobilize the injured tendon and allow for healing. The leg is casted for 4 to 9 weeks followed by immobilization in a walking boot for an additional 4 to 12 weeks. After immobilization, strengthening and stretching exercises are recommended to regain strength and a full range of motion. Nonsurgical treatment does not involve the risks associated with surgery (such as infection, bleeding, or nerve injury). However the recovery period is usually longer than with surgical intervention and there is a higher risk of re-rupture of the tendon.

Medication

If pain medication is necessary, nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

Do not take pain medication for 7 days before surgery.

Prescription pain relievers may be given by a caregiver. Use only as directed and only as much as you need.

Surgical treatment is performed to reattach the tendon to the calcaneus bone with sutures. After surgery the lower leg and foot are immobilized in a cast. After immobilization, strengthening and stretching exercises are recommended to regain strength and a full range of motion. The advantages of surgical intervention are shorter recovery, no need to immobilize the knee, lower risk of repeat rupture, and a stronger calf muscle after injury. The disadvantages include the risks of surgery, such as impaired wound healing, nerve injury, and infection.

SEEK IMMEDIATE MEDICAL CARE IF:

Pain increases, despite treatment.

Cast discomfort develops.

New, unexplained symptoms develop (drugs used in treatment may produce side effects).

EXERCISES

About 4 to 8 weeks after your cast comes off and if your physician, physical therapist, or athletic trainer feels your ankle has made progress significant enough to begin more advanced exercises, he or she may recommend some of the following exercises to progress your ankle mobility. He or she will likely advise you to continue with the exercises which you completed in Phase I of your rehabilitation. While completing these exercises, remember:

Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

An effective stretch should be held for at least 30 seconds.

A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

RANGE OF MOTION–Ankle Plantar Flexion

Sit with your right / left leg crossed over your opposite knee.

Use your opposite hand to pull the top of your foot and toes toward you.

You should feel a gentle stretch on the top of your foot/ankle. Hold this position for __________ seconds.

Repeat __________ times. Complete __________ times per day.

RANGE OF MOTION–Ankle Eversion

Sit with your right / left ankle crossed over your opposite knee.

Grip your foot with your opposite hand, placing your thumb on the top of your foot and your fingers across the bottom of your foot.

You should feel a gentle stretch on the inside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION–Ankle Inversion

Sit with your right / left ankle crossed over your opposite knee.

Grip your foot with your opposite hand, placing your thumb on the bottom of your foot and your fingers across the top of your foot.

Gently pull your foot so the smallest toe comes toward you and your thumb pushes the inside of the ball of your foot away from you.

You should feel a gentle stretch on the outside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH–Gastroc, Standing

Place hands on wall.

Extend right / left leg and place a folded washcloth under the arch of your foot for support. Keep the front knee somewhat bent.

Slightly point your toes inward on your back foot.

Keeping your right / left heel on the floor and your knee straight, shift your weight toward the wall, not allowing your back to arch.

You should feel a gentle stretch in the right / left calf. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRETCH–Soleus, Standing

Place hands on wall.

Extend your right / left leg and place a folded washcloth under the arch of your foot for support. Keep the front knee somewhat bent.

Slightly point your toes inward on your back foot.

Keep your right / left heel on the floor, bend your back knee, and slightly shift your weight over the back leg so that you feel a gentle stretch deep in your back calf.

Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRENGTHENING EXERCISES–Achilles Tendon Rupture Phase II

These are some of the exercises you may progress to in your rehabilitation program after completing the Phase I exercises for 4 to 8 weeks. Do not begin these until you have your clinician's permission. Although your condition has improved, the Phase I exercises will continue to be helpful and you may continue to complete them. As you complete strengthening exercises, remember:

Strong muscles with good endurance tolerate stress better.

Do the exercises as initially prescribed by your caregiver. Progress slowly with each exercise, gradually increasing the number of repetitions and weight used under his or her guidance.

You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

STRENGTH–Dorsiflexors and Plantar-flexors, Heel/toe Walking

Dorsiflexion: Walk on your heels only. Keep your toes as high as possible.

Use caution, these are advanced level exercises. Do not begin them until you are advised to do so.

Create a balance board using a sturdy board about 1½ feet long and at 1 to 1½ feet wide and a 1½ inch diameter rod or pipe that is as long as the board's width. A copper pipe or a solid broomstick works well.

Stand on a non-carpeted surface near a countertop or wall. Step onto the board so that your feet are hip-width apart and equally straddle the rod/pipe.

Tip the board from side-to-side. Control the movement so the board does not forcefully strike the ground. The board should silently tap the ground.

Tip the board side-to-side without striking the ground. Occasionally pause and maintain a steady position at various points.

Repeat the first 2 exercises, but use only your right / left foot. Place your right / left foot directly over the rod/pipe.

Repeat __________ times. Complete this exercise __________ times a day.

BALANCE–Plantar/Dorsi Flexion

Use caution, these are advanced level exercises. Do not begin them until you are advised to do so.

Create a balance board using a sturdy board about 1½ feet long and at 1 to 1½ feet wide and a 1½ inch diameter rod or pipe that is as long as the board's width. A copper pipe or a solid broomstick works well.

Stand on a non-carpeted surface near a countertop or wall. Stand on the board so that the rod/pipe runs under the arches in your feet.

Note: This exercise can place a lot of stress on your foot and ankle. Please complete this exercise only if specifically instructed by your caregiver.

Place the balls of your feet on a step. With your hands, use only enough support from a wall or rail to keep your balance.

Keep your knees straight and rise up on your toes.

Slowly shift your weight entirely to your right / left toes and pick up your opposite foot. Gently and with controlled movement, lower your weight through your right / left foot so that your heel drops below the level of the step. You will feel a slight stretch in the back of your right / left calf at the ending position.

Use the healthy leg to help rise up onto the balls of both feet, then lower weight only on the right / left leg again. Build up to 15 repetitions. Then progress to 3 consecutive sets of 15 repetitions.*

After completing the above exercise, complete the same exercise with a slight knee bend (about 30 degrees). Again, build up to 15 repetitions. Then progress to 3 consecutive sets of 15 repetitions.*

Perform this exercise __________ times per day.

*When you easily complete 3 sets of 15, your physician, physical therapist or athletic trainer may advise you to add resistance by wearing a backpack filled with additional weight.